Provider Demographics
NPI:1801005582
Name:BOHNSTEDT, STANLEY WALTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:WALTER
Last Name:BOHNSTEDT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33226
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-3226
Mailing Address - Country:US
Mailing Address - Phone:503-255-9339
Mailing Address - Fax:503-255-9375
Practice Address - Street 1:15012 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-2854
Practice Address - Country:US
Practice Address - Phone:503-255-9339
Practice Address - Fax:503-255-9375
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice